See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/11683499 Outcomes measurement for asthma following acute presentation to an emergency department Article in Australian health review: a publication of the Australian Hospital Association · February 2001 DOI: 10.1071/AH010053 · Source: PubMed CITATIONS READS 4 42 4 authors , including: Son ĵ E Hall Martin Phillips Queensland University of Technology Sir Charles Gairdner Hospital 32 PUBLICATIONS 1,022 CITATIONS 39 PUBLICATIONS 1,392 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: The Women’s wellness after cancer program: a multisite, single-blinded, randomised controlled trial View project Inequalities in Health Care and Outcomes for People with Cancer: A Western Australian Linked Database Study View project All content following this page was uploaded by Son ĵ E Hall on 26 May 2014. The user has requested enhancement of the downloaded file.
Outcomes measurement for asthma following acute presentation to an emergency department Outcomes measurement for asthma following acute presentation to an emergency department G EOFF M ASTERS , S ONJ E H ALL , M ARTIN P HILLIPS , AND D UNCAN B OLDY Geoff Masters is the Executive Medical Director at King Edward Memorial/ Princess Margaret Hospitals. Sonj E Hall is a lecturer in the Department of Health Policy and Management in the School of Public Health at Curtin University of Technology . Martin Phillips is Head of the Department of Respiratory Medicine at Sir Charles Gairdner Hospital. Duncan Boldy is Head of the Department of Health Policy and Management in the School of Public Health at Curtin University of Technology . Abstract The Asthma Management Plan (AMP) was developed by the Thoracic Society of Australia and New Zealand in 1989 to provide a more uniform approach to asthma care, aimed at reducing mortality , morbidity and emergency presentations. The AMP is often supplemented with Asthma Clinical Pathways (CPs) within the emergency department and hospital setting. This study was designed to evaluate the impact of these two instruments on asthma outcomes one month after presentation to the emergency department. The AMP and CP were both found to have had positive influences on asthma management. However, the study illustrates that there continue to be problems with asthma management, which would be improved by a more consistent use of these instruments. Introduction Since the early 1980s, asthma in Australia has increased in prevalence at about 0.5% per year (Bauman, 1998). Over this period, Bauman (1998) reports that asthma in children increased from a prevalence of 10% to 20% whilst in adults the increase has been from 7% to 12%. Mortality rates from asthma have dropped over 50% from 1.5 deaths per 100,000 in 1992 to less than 0.8 deaths per 100,000 in 1995. Bauman (1998) and Yoon et al (1993) attribute this decline to the combined effect of improved asthma management and better education of patients including the use of the Australian Asthma Management Plan (AMP). In 1989, the AMP was developed in an attempt to create a unified approach to the management of asthma (Woolcock et al, 1989). However, a study in South Australia six years later, showed that less than half of people with asthma use an AMP (Beilby et al, 1997). Increased uptake would be expected to reduce the preventable morbidity and mortality , severity and number of emergency presentations from asthma that are currently occurring. In addition to AMPs, clinical pathways for asthma have been developed by many hospitals. In the study we are to describe, an Asthma Clinical Pathway (CP) was developed for a specific large tertiary hospital, using the definitions of asthma severity (National Asthma Campaign, 1992, 1993) and with consideration of the medical evidence for best practice (Beveridge et al, 1996, Woolcock et al, 1989, 1994). The pathway was designed to replace existing paperwork associated with assessment and treatment in the emergency department and includes referral of those 53
Australian Health Review [Vol 24 • No 3] 2001 discharged from the emergency department to an Asthma Clinic for further education, assessment and treatment. The evaluation of clinical pathways has typically focused on reducing length of stay and costs rather than on quality of care or health outcomes. In fact, little is known about the latter for patients with asthma who present to an emergency department. In particular, those who are treated and sent home are thought to have poor compliance with follow up (Bauman et al, 1995). They are therefore a group where the implementation in the emergency department of guidelines for assessment, treatment and follow up may yield a significant improvement in outcome. This study had two aims. The first was to define and demonstrate the measurement of asthma health outcomes and outcome related performance indicators in the community , one month after presentation to the hospital emergency department with asthma. In particular, the influence of the use of an AMP on these measures would be evaluated. The second was to assess the effect of an asthma clinical pathway on the process of assessment and treatment for patients with asthma and to measure its effect on asthma health outcomes. Methodology This was an interventional study with unblinded, unmatched internal controls. Patients who had presented at the emergency department with a diagnosis of asthma were identified from the hospital information system. The intervention group consisted of asthma subjects who presented after the implementation of the asthma clinical pathway whilst the control group subjects were those who had presented prior to implementation. The inclusion criteria limited participation to those aged over 17 years who were not admitted to intensive care. Ethical approval was gained from the hospital ethics committee. Asthma related health outcomes were measured by a structured telephone interview one month after the presentation. A chart audit was performed assessing both health outcomes and performance indicators and in the case of the intervention group, whether or not the clinical pathway had been implemented. Prior to commencing the study , the telephone interview , chart audit and clinical pathway documents were piloted on twenty subjects with asthma and the results used to refine the interview and audit processes. One primary outcome measure was the use of agonists (reliever medication) which are a class of medications used to relieve the symptoms of asthma and are generally used as a supplement to control and preventer medication for everyday use. An increased use of agonist medication often indicates poorly controlled asthma. Data collected during interview included the type of agonist medication used, frequency of use in the previous 24 hours, and asthma symptoms as measured by 1) nocturnal waking, 2) the need for agonist immediately on waking and 3) impairment of normal physical activity . The patient was also asked if they possessed a peak flow meter and an AMP , and whether they had been reviewed by a doctor within a month of their presentation to the emergency department with asthma. (A peak flow meter is a device that is used to monitor the airflow out of the lungs. Negative changes in airflow may indicate that the asthma is worsening and the patient needs to see a doctor). Performance indicators measured by chart audit included whether asthma severity was documented, prescription of steroid (‘preventer’) medications and the documentation of follow-up arrangements. There was also an asthma interval assessment, eliciting previous asthma symptoms, asthma self-management and episodes of care; factors that are associated with a high risk of poor outcome. Analysis of the data mostly involved the comparison of proportions using the chi-square test of association. The non-parametric Kruscal-Wallis test was used to compare the outcome of Asthma Symptom Scores, as the distribution of these scores was bimodal. Results Recruitment of the control group took place between February and June 1997 and consisted of 104 consecutive patients. The intervention group consisted of 97 consecutive patients presenting during the months of August to December 1997. Only two patients refused to participate in the telephone survey and 22 patients could not be contacted by telephone. Hence, the recruitment rate was 89%. The groups were similar in age ( χ 2 = 0.72, p 54
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